• Reference Number: HEY-427/2020
• Departments: Speech and Language
• Last Updated: 28 September 2020

Introduction

This leaflet has been produced to give you general information about your condition.  Most of your questions should be answered by this leaflet. However, it is not meant to replace the discussion between you and the healthcare team, but may act as a starting point for discussion.   If after reading it you have any concerns or require further explanation, please discuss this with a member of the healthcare team.

What is a chronic cough?

Acute cough – lasts less than three weeks usually due to upper or lower respiratory tract infections, asthma or if you have breathed in irritants such as smoke or chemical fumes. 

Subacute cough – lasts three to eight weeks, can be due to whooping cough, tuberculosis (TB) or if your airways are slow to settle down after an infection e.g. the germs are no longer there but your airways are still irritated which causes you to still cough.

Chronic cough – a persistent cough that lasts longer than eight weeks.

Possible causes of a chronic cough:

• Postnasal drip (mucus drips down from the back of your nose into your throat) as a result of hay fever, allergies, nasal polyps or infections.
• Laryngopharyngeal reflux (LPR) is stomach contents coming up and spraying into the airway can cause redness and swelling and triggers a cough.
• Side-effects of certain medications, for example angiotensin-converting enzyme (ACE) inhibitors commonly prescribed for high blood pressure and heart failure are known to cause chronic cough in some people.
• Aspiration- (food and / or drink entering the airway into the lungs) over time can cause pneumonia. If you notice that you are coughing when eating and drinking contact your doctor immediately.

Once the ear nose and throat (ENT) doctor has examined your larynx (voice box) and the doctors have ruled out any possible lung conditions, the following are some of the other common triggers of a chronic cough. In many cases there may be more than one cause

• Cold air
• Physical exercise
• Pollen
• Dust
• Aerosol sprays, strong smells cleaning substances
• Throat dryness

It can be an extremely upsetting and frustrating for the person. It may also lead to, or be accompanied by other problems such as:

• poor sleep
• disordered breathing
• dizziness
• loss of bladder control
• retching or vomiting
• syncope (passing out)
• anxiety
• social isolation – avoiding public places/socialising
• low mood
• headaches
• hoarse voice (dysphonia)
• vocal fold nodules
• vocal fold haemorrhage (bleeding)
• throat irritation
• throat discomfort and pain

What happens when you cough?

When you cough your breath is forced out through your airway which pulls your vocal folds together very forcefully.

It is important to understand the difference between a ‘productive cough’ and an ‘unproductive cough’

• Productive cough is one that shifts phlegm or food/liquid that has ‘gone down the wrong way’ out of the airway. This is our body’s way of protecting our airway in order to allow you to breathe normally.
• Unproductive cough (often a dry/tickly cough) can be triggered by many different factors (see below) e.g. throat dryness. Often the sensation of ‘something in the throat’ does not go away with coughing.

It is important to get treatment for your cough and if appropriate, learn how to control the cough as it can develop into a vicious cycle that may end in fits of choking, retching or vomiting.  It can also damage and harden the delicate lining of the vocal cords or rupture tiny blood vessels causing bleeding or vocal nodules. This may lead to dysphonia (a change in your voice quality e.g. hoarseness).

Treatments

This will really depend on the cause of your particular chronic cough.

• A reflux triggered cough – you may be prescribed a liquid alginate medication which forms a ‘raft-like’ protection over the stomach contents to prevent acid coming up and into the airway. (Ask your speech therapist for the leaflet on acid reflux).
• If you take medication which has a known drying effect on the larynx, or a ‘cough’ as a side-effect you may be advised to switch medications by your doctor.
• You may be prescribed inhalers for your asthma and advised to use a spacer device.
• You may be prescribed a steroid nasal spray for post nasal drip.
• If allergy related, you may be prescribed anti-allergy medications (be aware some of these may have a drying effect on the throat so do use good hydration measures).

Tips to reduce the triggers of coughing

• Keep a log of your cough and triggers.
• Is it related to anxiety or a habit e.g. coughing just before making a phone call? If so be mindful of this and make sure you relax your shoulders and take a gentle slow breath in through the nose and out through pursed lips relaxing your shoulders jaw and tongue. Try swallowing instead of coughing.
• Focus on abdominal breathing, your Speech Therapist can demonstrate a safe technique for you.
• Avoid known triggers e.g. animal fur, pollen etc.
• Stop smoking – consult your doctor or NHS website for advice on stopping smoking.
• If cold air is your trigger, loosely wrap a light scarf around your mouth when you go outside and use nasal breathing to warm and filter the air.
• If exercise is your trigger, try gentle nasal breathing in and out build up exercise tolerance gradually. If you have severe coughing fits during exercise or feel like you cannot breathe this can be linked to other upper airway disorders like induced laryngeal obstruction (ILO), this would need further investigation by an ENT doctor.
• Wear a mask if strong smells or dust is your trigger. Choose plant-based cleaning products without strong smells and avoid using chemical products such as bleach. Keep windows open when dusting and cleaning.
• Reduce acid reflux triggers e.g. modify lifestyle and diet – your Speech Therapist can offer more information and advice on this.
• If on medication that has a drying effect on the throat lining, regularly inhale steam and drink plenty of fluids.
• Avoid caffeine and alcohol (which can dry the throat out).
• Keep very well hydrated sipping water every 15 minutes throughout the day and aim to drink approximately 1.5 to 2 litres of water a day.
• Avoid medicated cough lozenges (especially those which contain menthol) as they can dry your throat out further. Try non-medicated honey based lozenges or menthol free, teeth whitening chewing gum to encourage regular swallowing.
• Breathing in steam, use a facial steamer or a bowl of boiled water with a towel over your head. Exercise caution with hot water and also gradually build your tolerance for steam e.g. initially start further away from the bowl building up to be nearer to the steam. Do not add anything to the water as this may irritate the lining of the throat.
• If your throat is dry, using air humidification (air humidifier or damp towel over the radiator) may be helpful.

Cough suppressant techniques

Once the larynx (voice box) becomes irritated, there usually is an urge to keep coughing.  At this point, or even before the cough starts, try and stop it. There is no ‘quick fix’ to stop a chronic cough, you are the best person to understand what triggers the cough and which cough suppression strategies work best for you.

It is important to practice the chosen technique(s) regularly and use them consistently.

The following techniques can be used in combination or rotation.  The only way to break the cycle is to keep working at suppressing the cough for as long as each bout of coughing continues. 

At the first sign of a tickle or if you feel a cough coming on, you can use a combination of the following:

1. Pause
2. Swallow hard several times
3. Relax your shoulders, jaw and tongue.
4. Sniff in quickly through the nose 2 to 3 times in succession and then blow out gently through pursed lips.  Breathing in through your nose warms and moisturises the air. Blowing out through the lips channels the air and ‘cushions’ the vocal cords to help reduce irritation

Or:

1. Breathe in quickly through pursed lips. Then breathe out in two bursts through pursed lips with your cheeks ‘puffed-out’
2. Once you have tried these you can attempt the following…
3. As the throat feels calmer, take a sip of water or cordial but only if you are confident it will not trigger the cough again
4. Inhale through the nose and breathe out making the sound ‘sssss’
5. Sucking an ice cube or sipping very cold water before a cough starts can sometimes prevent it

Other suggestions:

• If you need to blow your nose do this as gently as possible in order not to aggravate the upper airway.
• If you suffer with asthma or other breathing difficulties, does your inhaler reduce the desire to cough?  If so, seek advice from your doctor about using it as often as you need.
• If you feel you have to shift phlegm, cough as ‘gently’ as possible in order to reduce high impact of ‘loud’ coughing, your speech therapist can demonstrate the ‘silent – huff’ cough method. If you have excessive phlegm it may be advised to seek support from a physiotherapist.

REMEMBER

1. Practice these techniques even when you are not coughing.  This will remind you to use the techniques when you do start coughing again.

1. Keep working at suppressing the cough for as long as each bout of coughing continues.  It is the only way to break the cycle.

1. Seek advice from your doctor regarding any medications that may be causing the cough or could be prescribed to improve it.  A cough may be caused by several different factors.

1. If you have had a persistent cough for some time, your doctor may wish to consider referring you to the Cough Clinic at Castle Hill Hospital where a consultant chest physician specialising in chronic cough accepts referrals from all over the UK.

Should you require further advice on the issues contained in this leaflet, please do not hesitate to contact The Speech and Language Therapy Department (01482) 604331.

General Advice and Consent

Most of your questions should have been answered by this leaflet, but remember that this is only a starting point for discussion with the healthcare team.

Consent to treatment

Before any doctor, nurse or therapist examines or treats you, they must seek your consent or permission. In order to make a decision, you need to have information from health professionals about the treatment or investigation which is being offered to you. You should always ask them more questions if you do not understand or if you want more information.

The information you receive should be about your condition, the alternatives available to you, and whether it carries risks as well as the benefits. What is important is that your consent is genuine or valid. That means:

• you must be able to give your consent
• you must be given enough information to enable you to make a decision
• you must be acting under your own free will and not under the strong influence of another person

Information about you

We collect and use your information to provide you with care and treatment. As part of your care, information about you will be shared between members of a healthcare team, some of whom you may not meet. Your information may also be used to help train staff, to check the quality of our care, to manage and plan the health service, and to help with research. Wherever possible we use anonymous data.

We may pass on relevant information to other health organisations that provide you with care. All information is treated as strictly confidential and is not given to anyone who does not need it. If you have any concerns please ask your doctor, or the person caring for you.

Under the General Data Protection Regulation and the Data Protection Act 2018 we are responsible for maintaining the confidentiality of any information we hold about you. For further information visit the following page: Confidential Information about You.

If you or your carer needs information about your health and wellbeing and about your care and treatment in a different format, such as large print, braille or audio, due to disability, impairment or sensory loss, please advise a member of staff and this can be arranged.